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SANPJ0AQUIN Environmental Health Department COUNTY— Greatness grows here Monitoring Well/Soil Boring Inspection Report Date:. �It� 1� Inspector: A• r')oAS CONSTRUCTION Facility Address:,S01 S ,, �12 pq A, Well Address: Total Depth: WP# Well#: Drilling Rig Type: Soil Boring#: Min 2"Annular EHD Seal Verified: ❑ Yes ❑No Drilling Company: Driller Onsite: Screen Length From: To: Consultant: Aa(Ot,s Filter Pack From: To: Geologist: Bentonite From: To: Grout From: To: Public Water System Onsite: ❑ Yes El No COMPLETION ❑ Stove Pipe ❑Christie Box Domestic Well Onsite: ❑ Yes El No casing If yes, location and distance: height SAMPLING ABOVE-GROUND Holding Temperature: COWLErJON COMPL nON Method: Ground s"rrac' Screening Method: arm Verified Chain of Custody: ❑ Yes ❑No �ft. R" ft. ft. SPOILS = Contamination Noted: ❑ Yes ❑No — If yes, spoils storage Location: slonad s�c5on Covered: ❑ Yes ❑No Vavv4 pack If yes, material: GROUTING or DESTRUCTION Total Depth: IF _ Depth to Water: ft Grout Material: MATERIALS/DEVELOPMENT Gallons of Grout Used: — CL b)ft Casing Type: ❑Well Installation ❑Well Destruction Blank Feet Screen Feet El Boring Installation%oring Destruction Slot Size: Bags of Cement: METHOD USED Bags Sand/Gravel: Type/Brand of Bentonite: ❑Pressure Grout ❑Over Drill Filter Pack Type/Size: ,41 Gravity ❑Tremie ❑Other: Type of Method: Water Ce eht 471b Water Cement 941b allons Bags gallons Bags Thickest Thinnest B Thickest Thinnest 9Bags Bentonite/Cement Mix 3% Mix 5% Mix 2.5 5 1 Y 5 10 1 Bentonite per 47 lb 1.41 2.47 5 10 2 10 20 2 Bentonite per 94 lb 2.82 4.7 7.5 15 3 15 30 3 10 20 4 20 40 4 12.5 25 5 25 50 5 15 1 30 6 30 60 6 17.5 1 35 7 35 1 70 7 20 1 40 8 40 80 8 10/16/2017 1868 E. Hazelton Avenue Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.secehd.com